Harvard Kennedy School and School of Public Health, Boston, USA.
Global Health. 2011 Oct 12;7:39. doi: 10.1186/1744-8603-7-39.
Tiered pricing - the concept of selling drugs and vaccines in developing countries at prices systematically lower than in industrialized countries - has received widespread support from industry, policymakers, civil society, and academics as a way to improve access to medicines for the poor. We carried out case studies based on a review of international drug price developments for antiretrovirals, artemisinin combination therapies, drug-resistant tuberculosis medicines, liposomal amphotericin B (for visceral leishmaniasis), and pneumococcal vaccines.
We found several critical shortcomings to tiered pricing: it is inferior to competition for achieving the lowest sustainable prices; it often involves arbitrary divisions between markets and/or countries, which can lead to very high prices for middle-income markets; and it leaves a disproportionate amount of decision-making power in the hands of sellers vis-à-vis consumers. In many developing countries, resources are often stretched so tight that affordability can only be approached by selling medicines at or near the cost of production. Policies that "de-link" the financing of R&D from the price of medicines merit further attention, since they can reward innovation while exploiting robust competition in production to generate the lowest sustainable prices. However, in special cases - such as when market volumes are very small or multi-source production capacity is lacking - tiered pricing may offer the only practical option to meet short-term needs for access to a product. In such cases, steps should be taken to ensure affordability and availability in the longer-term.
To ensure access to medicines for populations in need, alternate strategies should be explored that harness the power of competition, avoid arbitrary market segmentation, and/or recognize government responsibilities. Competition should generally be the default option for achieving affordability, as it has proven superior to tiered pricing for reliably achieving the lowest sustainable prices.
分层定价——即在发展中国家以低于工业化国家的系统价格销售药品和疫苗的概念——得到了业界、政策制定者、民间社会和学术界的广泛支持，认为这是改善穷人获得药品的途径。我们对艾滋病毒、青蒿素联合疗法、耐多药结核病药物、脂质体两性霉素 B（用于内脏利什曼病）和肺炎球菌疫苗的国际药品价格发展进行了案例研究。
我们发现分层定价有几个关键缺陷：它不如竞争那样能实现可持续的最低价格；它通常涉及到市场和/或国家之间的任意划分，这可能导致中等收入市场的价格非常高；它使销售者相对于消费者拥有不成比例的决策权。在许多发展中国家，资源往往非常紧张，只有以接近生产成本的价格销售药品，才能实现可负担性。“将研发融资与药品价格脱钩”的政策值得进一步关注，因为这些政策既能奖励创新，又能在生产中利用激烈的竞争来产生可持续的最低价格。然而，在特殊情况下——例如市场规模非常小或缺乏多源生产能力——分层定价可能是满足短期获得产品需求的唯一实际选择。在这种情况下，应采取措施确保长期的可负担性和可获得性。
为了确保有需要的人群能够获得药品，应探索利用竞争力量、避免任意市场分割和/或承认政府责任的替代策略。竞争通常应该是实现可负担性的默认选择，因为它已被证明优于分层定价，能够可靠地实现可持续的最低价格。
